CONJUNCTIVOPLASTY IN CERTAIN CORNEAL AFFECTIONS JOHN GREEN, M.D., F.A.C.S.

SAINT LOUIS

The cases successfully treated with a conjunctival flap included ulcer, perforation of the cornea, and inveterate pannus. The advantages of this treatment are rapid healing and prompt relief from pain. Read at the annual meeting of the American Ophthalmological Society, Quebec, June 27, 1927.

The several processes concerned in the repair of corneal denudations and ulcers may be classified as follows:

(1) Extension of an epithelial sheet from the borders of the lesion to cover the defect;

(2) Insinuation of blood vessels into the corneal tissue in the direction of the lesion, associated (in some cases) with a slough of necrotic and infected ma­terial covering the base of the ulcer; and, finally, epithelialization;

(3) Development of a true tongue of conjunctiva, extending over the lesion and becoming adherent to it, thus forming a pseudopterygium. (This process is most familiar in chemical burns of the cornea.)

A typical example of repair by the first process is in the case of superficial noninfected abrasions. We are all familiar with the surprising rapidity with which epithelium covers over these defects. The repair is usually so perfect that the minutest scrutiny with the corneal microscope and slit lamp fails to reveal any evidence of former injury; and in the case of central denudations recovery is without visual impairment. Following the indications of this simple process of repair the most effective treatment is by mild antiseptics, with a bland ointment containing hyoscin and holocain, and the wearing of an occlusive dressing for a day or so.

In the case of true ulcers, measures designed to enhance the natural process have proved most efficacious. Dilata­tion of the new-formed blood vessels and local increase in circulation are promoted by dry or moist heat. Lym­phatic activity is increased by dionin. Infection is combated by antiseptic collyria, or more effectively by topical application of strong antiseptics, cau-terants, or heat, often supplemented by

curettage. An accompanying iritis is controlled by atropin.

Measures such as these are curative in the majority of denudations and ulcers, whatever their origin and whether infected or noninfected. When, however, they fail, as they occasionally do, I suggest that we give heed to nature's third process of repair, and fashion some form of conjunctival flap for temporary or permanent coverage of the corneal lesion. There is nothing novel in this suggestion. Conjunctivo-plasty in corneal ulcer has been lauded by a limited number of ophthalmic surgeons. I suspect, however, that these advocates have often been re­garded as "faddists" and hence their example has not been widely followed.

A conjunctival flap, if thought of at all, is considered as a last resort, and is then used with trepidation rather than with confidence. Such an attitude is, I believe, unwarranted. A con­junctival covering to an ulcer serves several purposes: First, it is a most efficient method of controlling pain incident to exposure of sensory nerve endings. Second, it protects the de­nuded area from any detrimental ex­ternal influences such as wind, dust, palpebral irritation, or conjunctival secretions. Third, the serum transuded from the vessels of the flap forms a nonirritating film which by the direct action of antibodies probably aids in the repair of the lesion.

In my experience conjunctivoplasty has proved especially valuable in the following types of cases:

(1) Marginal ulcer. (2) Inveterate pannus, persisting

after the subsidence of acute trachoma. (3) Serpiginous ulcer. (4) Hernia of Descemet's membrane

following the perforation of a serpent ulcer.

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CONJUNCTIVOPLASTY IN CERTAIN CORNEAL AFFECTIONS 13

(5) Perforation of the cornea follow­ing central syphilitic keratitis.

(6) Ulcer of the Mooren type. (7) Ring ulcer of the cornea. Inveterate pannus and marginal

keratitis.—R. W., aged 38 years, male, was first seen December 27, 1923. He had long been a victim of chronic trachoma. Recurrent attacks of pannus accompanied by small ulcers compelled him to stop work for two or three weeks, and, as these attacks came several times a year, his work—that of a machinists helper on a railroad—had been seriously interfered with. Local treatment consisting of holocain, hyos-cin, silver nitrate, and scarlet red salve failed to eradicate the pannus or to prevent ulceration. Pain was a con­spicuous feature, and by reason of its frequent recurrence and long con­tinuance was rapidly undermining the patient's morale. On March 17, 1924, he developed a marginal ulcer located from seven to nine o'clock.

The entire area of the pannus and ulcers at the upper limbus was curetted. Partial peritomy was performed at this site and a conjunctival flap drawn down to cover the entire curetted area. The marginal ulcer from seven to nine o'clock was curetted and another small conjunctival flap was drawn up to cover this area. The patient was seen again two years later. His eye had remained entirely free from ulcers or pannus. There was a small conjunctival cyst at nine o'clock adjacent to the cornea. This was removed, and one suture was inserted. Vision 20/30.

A more extensive use of this method is reported by Starr1, who in a case of nearly complete thick vascular pannus dissected off the latter and covered the denuded area with a conjunctival flap. Useful vision was restored.

Serpiginous ulcer.—E. N. T., male, aged 59 years, had had recurrent at­tacks of ulceration of the right cornea for twelve years. The present trouble began two months ago. Treatment at an eye clinic for seven weeks was with­out improvement. The right conjunc­tiva was inflamed and velvety. An irregular serpiginous ulcer occupied the central portion of the cornea. General

condition, fair. Wassermann, negative. Local treatment, silver nitrate one per­cent scrubbed on the upper lid, holocain • one percent, atropin and cocain in oil three times a day, dry heat, and boric acid flush. On June 7, my assistant, Dr. C. A. Hobart, incised the con­junctiva adjacent to the lower corneal margin and drew the flap upward with several interrupted silk sutures. The following day two of the sutures had pulled out. They were reinserted, and the flap drawn up again. The operation was followed by immediate relief from pain. Four days after the first opera­tion, the flap had almost entirely re­tracted. The staining area had dimin­ished about fifty percent. Ten days later there was a slight extension of the denuded area, accompanied by pain. This yielded to routine treatment. When the patient was last seen, October 29, the eye was white and quiet; vision 6/32.

Keratocele following hypopyon kera­titis.—M. G., aged 65 years, was seen at the city hospital eye clinic with hypopyon keratitis. The ulcer occupied the lower outer quadrant. Perforation soon took place, with evacuation of the hypopyon, followed by a hernia of Descemet's membrane. The eye was very irritable (ciliary congestion, lacri-mation). Tension was minus. The conjunctiva was incised for about one third of its circumference at the lower corneal margin, undermined, and drawn up to cover the ulcer completely. Heal­ing took place without incident and the flap retracted save at the site of the ulcer, where a little tongue became firmly adherent. A year later a cataract was successfully extracted after pre­liminary iridectomy.

An equally favorable result following a similar procedure is reported by Kuhnt2. Cirincione3 has successfully used complete conjunctival coverage of a hypopyon ulcer after cauterization and trephining a t the limbus.

Central keratitis with perforation.— E. D., aged 34 years, presented himself at the city hospital eye clinic with disc­shaped deep infiltration of the left cornea. Wassermann, positive. A loss of epithelium centrally led to curettage

14 JOHN GREEN

of the central portion of the cornea. After this, epithelialization took place rapidly. Local treatment, atropin and mercurochrome. The patient also re­ceived mercurial inunctions.

Several months later he appeared with the statement that the eye had suddenly become very painful the night before. There was now a central per­foration of the cornea with prolapse of the iris. The patient was admitted to the hospital and treated for ten days with atropin, two percent mercuro­chrome, fomentations, mercurial in­unctions, and sodium salicylate in­ternally. The perforation showed no tendency to close. The conjunctiva was completely circumcised and under­mined and a silk purse-string suture run around the edge. An attempt was then made to replace the prolapsed iris, and this seemed to be successful. The purse-string suture was drawn up, tied, and reinforced with two additional silk sutures. Binocular bandage.

The operation was followed by almost immediate relief from the pain, which had been quite severe. At the first dressing on the sixth day following the operation, the suture had partially pulled out, and it was found that the anterior chamber had reformed. After full retraction of the flap the iris was found adherent to the scar at the temporal side.

A case closely resembling the fore­going is reported by Muirhead4. A kera-titis resembling an interstitial keratitis began at the periphery and extended to the center, where perforation took place. Recovery with fair vision followed curettage of the edges of the perforation and the placing of a con-junctival flap.

Ulcer of Mooren type—spastic en-Iropion—iritis.—J. M. L., male aged 58 years. In March, 1924, the left eye became inflamed and painful. The patient believed that the cause of the trouble was the reception in the eye of some embalming fluid. Treatment covering a period of six weeks had not helped.

Examination showed a spastic en-tropion and a marginal ulcer with undermined edges running from four

to eight o'clock. The depth of the ulcer, its situation and ragged overhanging edges, suggested an ulcer of the Mooren type. There was diffuse staining of the lower half of the cornea and a low grade iritis. The usual local treatment was unsuccessful. Several ulcerated dental roots were extracted. The patient was given several milk injections with the usual systemic reaction, but without improvement in the ocular condition. A semilunar strip of skin was excised from the lower lid, the entire ulcerated area was curetted, and a conjunctival flap was drawn up to cover the entire area of the ulcer. Recovery was un­eventful. The flap retracted partly, but remained adherent over the site of the ulcer. The patient was seen a year later. The eye was entirely well. Vision, owing to an exudate in the pupil, was only 1/50.

Any method which offers a fair prospect of checking the progress of this type of ulcer should be seriously considered and promptly practised. Most of the reported cases indicate the futility of usual therapeutic measures. Evidence is accumulating that early coverage of the cornea with a conjunc­tival flap offers a fair prospect of a successful outcome. Cases in point are those of Marcard5 and Tyrrell6.

Ring ulcer of the cornea.—W. A., aged 30 years, consulted me several years ago on account of bilateral tra­choma. At this time the right upper eyelid was much thickened, with forma­tion of scar tissue and entropion. There was pannus with repeated ulceration. In the left eye the conjunctiva was thick and velvety but there was no pannus. I excised the tarsal cartilage of the right eye, followed by prompt improvement and ultimate cure of the trachoma. The condition of the left eye did not justify operation at this time, and consequently medical treat­ment only was resorted to. When last seen both eyes were quiet and it ap­peared that the trachomatous process in the left eye was quiescent. About August 15, 1925, the patient thought that he got a cinder in his left eye. At any rate, the eye became acutely in­flamed and painful. On September 1,

CONJUNCTIVOPLASTY IN C E R T A I N CORNEAL A F F E C T I O N S 15

1925, he was seen by my assistant, who found an acutely inflamed eye with pannus and ciliary injection. The patient was advised to remain for treat­ment but declined to do so. He returned to his home town, where a local oculist performed an excision of the tarsal cartilage. Apparently loop sutures with the knots on the conjunctival surface were used. At any rate there was an extreme amount of irritation and pain following the operation, so that nar­cotics had to be resorted to. The sutures were removed at the end of the third day but the patient's suffering continued unabated. Finally, on Sep­tember 21 he returned to St. Louis. The condition at this time was desperate. The entire periphery of the cornea was occupied by a deep ring ulcer which had destroyed all but a little island of epithelium not more than 2.50 mm. in diameter in the center of the cornea. Fortunately, perforation had not taken place, and the pupil, which could be dimly seen, was round and active. The patient had spent several sleepless nights, and was much prostrated by his suffering.

The ulcer was lightly curetted. The conjunctiva was completely circum­cised, freely undermined, and a silk purse-string suture run through the edge of the flap thus formed. When the purse-string was drawn taut, the entire corneal surface was covered by the flap.

The patient spent a comfortable, almost painless night, and slept soundly. To curtail the history, it may be said that he made an excellent re­covery, but the conjunctiva became adherent to all but the central part of the cornea. I t has been interesting and surprising to note the increasing thinning and transparency of the mem­brane, so that it became possible to discern easily the texture of the iris and the motility of the pupil. Needless to say, vision is low—1/60.

Recently (June 5, 1927) I dissected off the flap. I t was rather loosely ad­herent in all but two or three places. Owing to the large amount of irregular astigmatism much visual improvement is not to be expected, but the improve­ment in the appearance of the eye is noteworthy.

Treatment for ring ulcer has gener­ally been unsatisfactory. When the process has not compelled enucleation, it has not rarely resulted in a blind eye. Recently Post7 reported an excellent result—healing of the ulcer with good vision—from the application to the ulcer of Shahan's thermophore at 150°F. for one minute.

In a rather careful search of the liter­ature of the past twenty years I have found no instance of complete ring ulcer treated with a conjunctival flap. I am convinced that in this case it was the means of saving the eye with a little vision.

Beaumont building.

References 1 Starr. Conjunctival flap in the treatment of corneal infections and pannus. Trans. Amer. Acad.

Ophth. and Oto-Laryng., 1912, p. 17. 2 Kuhnt. Treatment of corneal fistula. Zeit. f. Augenh., v. 32, p. 421. 3 Cirincione. Surgical treatment of hypopyon keratitis. Clin. Ocul., v. 14, p. 601. 4 Muirhead. Corneal fistula. Med. Jour. Australia, 1922, Dec. 16, p. 720. 6 Marcard. Mooren's rodent ulcer of the cornea. Arch. d'Opht., v. 34, p. 147. 6 Tyrrell. Mooren's ulcer treated with conjunctival flap. Trans. Ophth. Soc. United Kingdom,

v. 37, p. 205. 7 Post. Thermophore treatment of ring ulcer of the cornea. Amer. Tour. Ophth., 1925, v. 8,

pp. 486-87.